<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603111
Report Date: 09/01/2022
Date Signed: 09/01/2022 01:08:27 PM

Document Has Been Signed on 09/01/2022 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A & A CARE HOMEFACILITY NUMBER:
198603111
ADMINISTRATOR:CABALLES, CRISTINAFACILITY TYPE:
735
ADDRESS:21207 WILDER AVETELEPHONE:
(562) 233-3125
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Cristina Caballes - AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Cristina Caballes and explained the reason for the visit. The facility is licensed to serve 1 ambulatory and 3 non-ambulatory clients ages 18-59. The facility is operating within the scope of its license.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included: 4 client bedrooms, 2 bathrooms, kitchen, dining room, living room, activity room, backyard, attached garage.

LPA Mora conducted the tour with Cristina Caballes and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet and in each bedroom. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. Client and staff files are kept locked in the activity room. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats and have the required grab bars for non-ambulatory clients. The water temperature was tested in both bathrooms and measured at 115.5 degrees F and 117.5 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A & A CARE HOME
FACILITY NUMBER: 198603111
VISIT DATE: 09/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed medication for all 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 4 staff. The physician report for 3 clients was either missing or incomplete. Staff files were missing the health screening form and First Aid/CPR certificate. Administrator stated that they do have them but were unable to be located during the visit. LPA observed administrator certificate for Cristina Caballes - 6045504735 with an expiration date of 08/20/2023.

Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/01/2022 01:08 PM - It Cannot Be Edited


Created By: Luis Mora On 09/01/2022 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A & A CARE HOME
FACILITY NUMBER: 198603111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
1
2
3
4
Licensee will obtain a completed health screening form for S1 - S4 and submit a copy to CCLD by 09/15/2022.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
1
2
3
4
Licensee will obtain a current First Aid/CPR certificate for S1 - S4 and submit a copy of the certificate to CCLD by 09/15/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/01/2022 01:08 PM - It Cannot Be Edited


Created By: Luis Mora On 09/01/2022 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A & A CARE HOME
FACILITY NUMBER: 198603111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 client files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
1
2
3
4
Licensee will obtain a completed physician report for C1, C2 and C4 and submit a copy to CCLD by 09/15/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4